Sage Kemp

Background

The owner reported that Sage, a 12 year old Dalmation had been suffering with intermittent lameness approximately a year before coming to see us, but this had settled with rest.

Rupture of the cranial cruciate ligament had then been diagnosed affecting the right stifle and the cruciate was subsequently repaired locally. Sage was then referred to Fitzpatrick Referrals for further treatment of the stifle following breakdown of the initial cruciate repair and spinal pain.

Condition on Presentation

Sage presented on 1^st May 2008 for assessment of continuing right pelvic limb lameness which had initially occurred 10 weeks earlier. Since having cruciate repair surgery locally weight-bearing had been intermittently evident but lameness was also present to a significant extent, hence his referral to us.

Diagnosis

If it wasn’t for the physiotherapy, Sage wouldn’t be around. I’m also sure it has kept him nimble. The difference the physio has made is wonderful. It’s brilliant. I’m over the moon that he hasn’t had to have an operation.

Sage's owner

Clinical examination on the day of assessment revealed significant muscle wastage of the right pelvic limb. Periarticular fibrosis of the right stifle was evident but the right stifle was still positive for cranial draw and cranial tibial thrust. Discomfort was evident on manipulation of the stifle, particularly on deep digital pressure application to the caudo-medial aspect of the stifle. Discomfort was also evident on deep digital pressure to the lumbo-sacral spine and the sciatic outflow on the right pelvic limb. The same was true to a lesser extent for the sciatic outflow of the left pelvic limb in the caudal recess of the biceps femoris.

It was decided that MRI scan should be performed of the lumbo-sacral spine before further investigation of the stifle.

MRI scan of the entire spine revealed a significant disc protrusion at the lumbo-sacral junction which was causing moderate cauda equina compression and significant right-sided L7 nerve root compression. A moderate disc protrusion was also evident at L6/L7 and there were multiple dehydrated discs throughout the lumbar spine. In the cervical area the disc at C2/C3 was dehydrated as was the disc at C6/C7 but no compressive lesion was noted. It was felt that the stifle problem had exacerbated the lumbo-sacral disc problem 

Radiography of the right stifle revealed progressive osteoarthritis with periarticular osteophytosis of the distal femur and the proximal tibia, enthesiophytosis of the distal patella and synovial effusion evidenced as opacification encroachment of the infrapatellar fat pad and caudal bulging of the subgastrocnemius fascial plane. The metal crimps were evident where the fabello-tibial tuberosity suture had been placed. The tibial plateau angle was 27 degrees.

Surgical exploration of the right stifle revealed caudal pole radial tear of the medial meniscus so a tibial plateau-levelling osteotomy and menisectomy were scheduled. The owner was made aware that should lameness fail to subside following this intervention then lumbo-sacral distraction fusion to alleviate neuropraxia of the L7 nerve root might have been necessary in due course.

Treatment

Surgery

A TPLO was performed on May 1^st  by the Slocum technique. A 24 mm biradial saw blade was employed and the proximal segment was rotated 9 mm and anchored with a pre-contoured 3.5 mm Orthomed plate and K-wire. Sagittal realignment of the calcaneo-patellar axis was achieved before anchorage of the proximal segment. A large portion of the caudal pole of the medial meniscus was excised followed by medial meniscal release caudal to the medial collateral ligament. Postoperative radiography revealed satisfactory alignment and stability. Cage rest was then enforced for six weeks with lead-only walking for 12 weeks.

Rehabilitation

A course of physiotherapy was scheduled to manage the lumbo-sacral disc disease as it was hoped that this condition could be managed conservatively and without surgery if at all possible. Physiotherapy also would help improve mobility following TPLO surgery.

Condition on Presentation (2)

Sage presented on 12^th June 2008 for reassessment subsequent to tibial plateau-levelling osteotomy on the right stifle performed on 1^st May and to reassess the management of lumbo-sacral disc disease. The response to physiotherapy for the lumbo-sacral spine had been very positive and this was to continue weekly for the next six weeks with monthly revisits thereafter.

It was explained to the owner that we would adopt surgical intervention on the lumbo-sacral spine if necessary based on impairment of quality of life. Clinical examination of the right stifle revealed satisfactory motion without pain and Sage was walking well on the right pelvic limb. Radiography indicated satisfactory healing of the osteotomy and full-range exercise was advised after a further six weeks.

Rehabilitation

Weekly physiotherapy continued and the lameness steadily improved. Spinal discomfort was dramatically reduced and Sage was regularly treated with passive mobilisation exercises and h-wave. The owner was also instructed how to use a TENS machine for pain relief. A course of hydrotherapy was instigated to improve general mobility, increase muscle mass and increase range of movement. By the end of the six week period Sage was much improved generally with no sciatic pain and only mild right lumbar pain and slightly tight adductor muscles. He was treated with soft tissue massage and TENS and physiotherapy continued every two weeks. The owner was given an updated set of home exercises to perform on a daily basis.

By the end of September Sage was completely sound, with full range of motion in the stifle and pain free. Nothing abnormal was detected in the spinal region at this stage. Physiotherapy assessment was advised to continue on a regular basis just to check progress and for further treatment as necessary.

Condition on presentation (3)

Sage represented on the 5^th November 2008 for assessment of left pelvic limb lameness.  A tibial plateau levelling osteotomy was performed on the left stifle for cranial cruciate ligament rupture as had previously been performed on the right stifle. Pre-operative radiography revealed progress degenerative joint disease of the left stifle with periarticular osteophytosis affecting the distal femur, the distal patellar and the proximal tibia and synovial effusion evidenced as opacification encroachment of the infrapatellar fat pad and caudal bulging of the subgastrocnemius fascial plane.  The tibial plateau angle was 28 degrees.

Surgical exploration of the left stifle revealed rupture of the cranial cruciate ligament, the remnants of which were excised. The menisci were intact. A Tibial Plateau levelling osteotomy was performed by the Slocum technique.  A 24mm biradial saw blade was employed and the proximal segment was rotated 9.5 mm and anchored with a pre-contoured 3.5mm Orthomed^TM plate and K-Wire. Mild sagittal realignment of the calcaneo-patellar axis was achieved before anchorage of the proximal segment. Cage rest was enforced for six weeks with lead-only walking for 12 weeks.

Rehabilitation

Regular physiotherapy was scheduled post-operatively but unfortunately Sage became ill with kennel cough, so this had to be postponed until after his six week post-operative check up.

Condition on presentation (4)

Sage presented on 8^th January 2009 for veterinary assessment following TPLO surgery. He was walking well on the affected limb without lameness or pain. Radiography revealed satisfactory progression of osseous union.. 

Rehabilitation

Physiotherapy for lumbo-sacral discomfort was re-introduced at our rehabilitation centre.

Sage has continued to come for regular physiotherapy assessment and treatments every six weeks since then (January 2009). He has continued to do really well but owing to his very boisterous nature he has needed physiotherapy treatment every so often. He has had episodes where he has been playing with other dogs too much and become sore. He has been treated with a range of treatments including trigger point therapy, soft tissue release, passive mobilisation exercises and deep massage. The owner is delighted with the results and further surgery has been unnecessary so far as Sage is comfortable with an excellent quality of life.

Sage’s owner

“If it wasn’t for the physiotherapy, Sage wouldn’t be around. I’m also sure it has kept him nimble. The difference the physio has made is wonderful. It’s brilliant. I’m over the moon that he hasn’t had to have an operation. By coming for physio every six weeks it has hopefully prevented him from having back surgery at all. He is twelve years old but he is still able to go for three to four walks a day which is wonderful”